Contraceptive choices for women with endocrine complications

Concepts of contraception for adolescent and young adult women with chronic illness and disability

Sexual behavior is common in adolescents and young adults with or without chronic illness or disability, resulting in high levels of unplanned pregnancy and STDs. Individuals with chronic illness or disability should not receive suboptimal preventive health care. These individuals have a need for counseling regarding issues of sexuality and contraception. Sexually active adolescent and young adult women can be offered safe and effective contraception if they wish to avoid pregnancy. Women with chronic illnesses and disabilities who are sexually active should also be offered contraception based on their specific medical issues. Condoms are also recommended to reduce STD risks. Table 36 summarizes basic principles of contraception application for specific illnesses, which have been identified since the release of the combined OC in 1960. Clinicians should also consider the noncontraceptive benefits of this remarkable and life-changing technology that allows all reproductive age women to improve their lives, including those with chronic illnesses and disabilities.

The clinical content of preconception care: women with chronic medical conditions

This article reviews the medical conditions that are associated with adverse pregnancy outcomes for women and their offspring. We also present the degree to which specific preconception interventions and treatments can impact the effects of the condition on birth outcomes. Because avoiding, delaying, or achieving optimal timing of a pregnancy is often an important component of the preconception care of women with medical conditions, contraceptive considerations particular to the medical conditions are also presented.

Oral contraceptives and the management of hyperandrogenism-polycystic ovary syndrome in adolescents

Appropriate management of polycystic ovary syndrome in adolescents depends on recognizing the syndrome, which can have a variety of presenting complaints and must be differentiated from other causes of hyperandrogenism, as well as not dismissed as "normal adolescence." Oral contraceptives have long been considered the first line of treatment by obstetrician/gynecologists and have many advantages in treating the aspects of PCOS that are most bothersome to teens. Because of the potential risk for cardiovascular disease, early diagnosis and management may be helpful in minimizing the risk of the early metabolic correlates of adult disease.

Prolactin disorders

OBJECTIVE

To review the pathophysiology, clinical manifestations, current diagnostic procedures, and treatment options for disorders involving PRL production. Common clinical dilemmas are discussed in a pragmatic fashion to guide the practitioner.

DESIGN

A world literature search of basic sciences and medical articles from the last three decades was performed using computerized MEDLINE. Recent endocrine and reproductive endocrine textbooks also were reviewed. Studies were selected for their degree of contribution to the basic sciences and clinical understanding of the disorder and for the quality of their study design and content. The information was summarized and grouped according to its relevance and application to specific sections of the manuscript. Studies were evaluated and critically used to support the views of the authors and to suggest specific clinical management strategies.

RESULT(S)

Disorders derived from abnormal PRL production are relatively common in clinical practice. Infertility, menstrual disorders, and galactorrhea are the most frequent manifestations encountered in women. Although frequently benign, the disorder occasionally may have severe consequences.

CONCLUSION(S)

An understanding of the underlying physiology and pathophysiology coupled with the awareness of the heterogeneous presentation of this disorder should help the clinician to approach it successfully.

The role of oral contraceptives in the treatment of hyperandrogenic disorders

The clinical manifestations associated with hyperandrogenism, such as hirsutism and acne, are disturbing to most patients. In addition to correcting androgen-related problems, concerns such as contraception or other metabolic problems (for example, lipid/lipoprotein abnormalities, diabetes, hypertension) associated with these disorders and the effects of unopposed estrogen on the endometrium also need to be considered. Oral contraceptives are a therapeutic modality that may address these multiple problems. The potential mechanisms of action by which oral contraceptives correct excess androgen states include gonadotropin suppression, reduction of circulating androgens, increased androgen binding, suppression of adrenal androgen secretion and inhibition of 5 alpha-reductase, and androgen receptor binding. In normal women, there is good evidence that these actions occur with the use of oral contraceptives. Among women with anovulatory hyperandrogenic states, such as polycystic ovary syndrome, the response to oral contraceptives in each of these areas is somewhat more variable. However, oral contraceptive preparations that are more estrogen dominant appear to produce many of the desired effects. From a clinical standpoint, 60-100% of women with hirsutism improve on oral contraceptives; acne shows improvement in a high percentage of women as well. The use of oral contraceptives also reduces the risk of endometrial hyperplasia that may be associated with anovulatory states. Finally, current low-dose preparations containing the newer progestins (for example, norgestimate and desogestrel) appear to be either neutral, or perhaps beneficial, with respect to their metabolic impact.

The gynecologist and the prevention of cardiovascular disease

This article reviews current concepts regarding the prevention of cardiovascular disease for women, with particular attention to modifiable risk factors. The background describes the magnitude of the problem, assesses the quality of the data with respect to risk factor reduction, and emphasizes several important concepts. Changes at menopause, states of endocrine aberration, and benefits and risks of hormone substitution need to be understood in conjunction with all other potentially modifiable and nonmodifiable cardiovascular risk factors. Primary care physicians have a window of opportunity to prevent this number one women's health problem. Integrating behavior modification is the key to prevention as part of the regular gynecologic visit.

Contraception for patients with psychiatric or medical disorders

The increased risk that pregnancy carries for women with medical disorders must be weighed against the risks of reversible contraception. In the absence of prospective randomized trials of various contraceptive methods and their effect on a given disease process, the clinician must use information regarding the risk of pregnancy in a woman with medical problems, the well-documented failure rates of various methods, and the probability that the patient will use the method (or any other method) effectively. The possible effects of contraceptive methods on cardiovascular, endocrinologic, neurologic, and other medical disorders are discussed as are appropriate contraceptive options and considerations for these women.

The gynecologist and cardiovascular disease: a window of opportunity for prevention

OBJECTIVE

We present current concepts and assess the quality of information available for the prevention of cardiovascular disease in women.

METHODS

This article reviews research bearing on the prevention of cardiovascular disease in women, with particular attention to modifiable risk factors. We describe the magnitude of the problem and assess the quality of the data with respect to the classic risk factors. The concept is emphasized that changes at menopause, states of endocrine aberration, and benefits and risks of hormone substitution and oral contraception must be understood in conjunction with all other potentially modifiable and nonmodifiable risk factors.

CONCLUSIONS

Primary care physicians, especially obstetrician/gynecologists, have a pivotal role to play in the reduction of this disease. Behavior modification is the key to integrating prevention into the regular annual visit.